FREEMAN NURSING & REHAB COMMUNITY MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/02/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/02/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
12/01/2010	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
12/01/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
12/01/2010	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
12/01/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/01/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/01/2010	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Isolated	Minimal harm or potential for actual harm
12/01/2010	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
12/01/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
09/02/2009	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Pattern	Minimal harm or potential for actual harm
09/02/2009	Hire a qualified activities director.	Widespread	Potential for minimal harm
09/02/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
09/02/2009	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
09/02/2009	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
09/02/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
09/02/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
09/02/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
09/02/2009	a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
09/26/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
09/24/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
09/24/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
09/24/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/24/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
09/24/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
09/24/2008	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Isolated	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death